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Insurance Nonsense and Health Care Reform Continued....

Picking up where I left off from two months ago. Basically I blew off some steam on how wasteful and unnecessary some systems that are set up by insurance companies have become. Much to my amazement, a few days after I submitted the first article on insurance, a representative of Aetna called my office with questions about how Aetna could streamline insurance submissions. I would like to think that my article, appearing on the Web, caused this behavior, but I am sure that was not the case. I have been rather critical of the insurance companies. I mention this call to praise them for doing something right.

The caller was doing research for Aetna on the use of electronic claim submission by area dentists. She noticed that my office was submitting many claims electronically but not all. In fact, I think she said about 45% of our claims were electronic with the remainder, paper claims. I would say this communication between company and dentist was a start. I was thrilled they were asking. My second thought was that I was surprised they didn't know the answer. Hey! I guess they can't read my mind (Only my wife can do that).

I dutifully explained that we would love to submit all of our claims electronically if they would allow us that luxury. They required perio measurements for any periodontal scalings. They required X-rays for crowns, bridges, etc. They required their company form to be submitted at least once per year or they would not pay. I guess this was news to them. Or maybe, one floor of the skyscraper doesn't know what the other floor is doing. I guess all that money in the halls makes it hard to pass memos around!

Well I give them credit. They did ask. Hopefully, the nice lady that called isn't a student intern doing a term paper for her health care reform class and they get the message! Maybe they now know how they can further delay claims by making it less likely I will submit via my trusty modem. The later thought is too pessimistic even for me!

Now I regress to a story told me by my associate, Dr. Greg Janikian, handed down from one generation to the next. This topic jumps back to the last article I wrote about insurance. I write this story down here to preserve it in cyberspace for those generations to come:

Once upon a time in the magical land of Insurance the great insurance King, before the coronation known as Small Prince (small print!), decided that if he could somehow further deny paying out claims to his subjects he would be even richer and play more golf. So, he asked the court wizard to create UCR. (The initials are in current time known to stand for U Could be Rich). The wizard worked very hard to ignore all rational thought and averages and basically picked a random number for each fee. Of course, these UCR numbers were all below what 99% of all dentists charged. Now even though the evil dentists would charge $560 for a crown the king could say "I will only pay a fee of $490 for a crown!" The great king just saved himself $70. The wizard then was promoted and bought a beach house in South Carolina.

Well so much for fairy tales, back to reality. Let's talk about interference in diagnosis, benefit denial. Yes, they say, they do not interfere in treatment planning but slowly they are doing just that. Techniques for second guessing the dental profession are increasing all the time. Examples include, deciding frequency allowed for X-rays, perio treatments, etc. True, patients can go ahead with treatment anyway but, and that's a big but, will they? Dictums from insurance companies are usually regarded by many patient's as the gospel according to Mark (OK maybe John). They do cast doubt on your diagnosis and treatment decisions.

Other examples include not paying for treatment period, or substituting say a partial denture for a fixed bridge. I don't have a problem with that strategy if the policy states they don't cover fixed bridges. If it covers fixed bridges they darn well should pay for a fixed bridge not suggest a partial. I had this happen with one patient of mine. The patient had only one missing molar #14. The remainder of his mouth was in excellent dental health. His policy booklet stated that fixed bridges were covered. The insurance company pre-determined that they would only pay for a removable partial. I wrote back and asked them under what conditions did they pay for a fixed bridge, as stated in the contract booklet. Did the patient need more missing teeth or what? Well they paid for the fixed work. Again, they are diagnosing and treatment planning. We should all be very alert for these tendencies and fight for our profession to maintain autonomy to make treatment decisions based on the diagnostic ability we have been trained to perform.

Here is a very dangerous example of an insurance carrier encroaching on judging the quality of our work. (By the way this should be reserved to dental boards or other dental peers). I had completed a molar root canal on one of my patients. Several months after completion the patient was still experiencing some pain in the area. I took a new X-ray and checked the film. I could see no reason why the tooth was still symptomatic. All canals seemed filled well. All looked good on the film. I informed the patient that I wanted a second opinion (perhaps an additional canal was present, crack, neuralgia etc.) I referred her to an endodontist. I really wasn't very optimistic that anything else could be done but I felt that I should have someone else take a look in case I was missing something! The patient proceeded to the specialist, who retreated the molar. He found no reason for the initial failure and his re treatment failed also. Now I understand the insurance companies problem. They paid me for the root canal. A re-treatment, at least if I messed up the initial treatment, would seem unfair for them to pay. On the other hand, sometimes our best attempts just don't work out or a specialized situation needs further treatment. That's why we have specialists.


The insurance company proceeded to take back the money it paid me for performing the root canal. IT GETS BETTER! They took the money out of a bulk check paid on other claims for other patients! Informing the patient and I that this was done because the tooth needed retreated! This is outrageous. They are implying all sorts of things they have no business commenting about. If they choose not to pay for retreatment, that's their choice. Why the tooth needs retreated and if any monetary compensation should be adjusted is definitely between the dentist, patient, and the specialist.

Moving along. The King in the above episode had another idea. He observed that his subjects were raising a ruckus about the premiums that they had to pay for medical and dental care. He again approached the wise wizard. He explained the problem and the wizard thought long and hard. He had to consult with the wicked witch of the big white house (she had been busy dabbling in commodity futures and real estate and it was difficult to get her attention) but finally he came up with another magical triad of letters, PPO. (This came to be known as, People to P*** On-----(fairy tales cannot use such words).

This was truly a plan that would insure profits for him. Heck, he could probably buy ALL the golf courses in North Carolina. He could offer the subjects a plan that would cost them less, he would make the same profit, and the isolated dentists trembling in fear of having no patients to rob, would assume most of the risk and gladly cut their salaries by 90%. The only thing that troubled the rich King was he would have no golfing partners because all the dentists would be working 100 hours a week to pay off their dental school debts. The other problem would be that there would not ever be any retired dentists to play golf with. He enjoyed playing against them for they were always easy to beat and would foolishly wager with him on each hole.

Well, bottom line: What constructive ideas do I have about insurance reform? Here is my list:

The real bottom line is that, for dentistry, not necessarily medicine, employers should be using direct reimbursement plans. Why have the middle man make a profit? They can control the risk totally with co-pays and yearly maximums.

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